2015 Communicable Disease
Summary and
Reporting Rule Revisions
APIC Spring Conference
April 8, 2016
Joshua Clayton, PhD, MPH
Deputy State Epidemiologist
2
2015 Statewide Data
3
District Count Rate*
1 5 0.6
2 20 3.1
3 12 1.7
4 5 1.4
5 46 2.6
6 15 2.3
7 4 1.4
8 8 2.2
9 9 2.0
10 11 2.3
Total 135 2.1
Shiga-toxin producing E. coli
181
121 117 135
0
50
100
150
200
2012 2013 2014 2015
Year
Male 63 (47%)
Female 71 (53%) 0
10
20
30
40
Age of Cases in Years
2015 Provisional Data
* Rate per 100,000 population
4
District Count Rate
1 0 –
2 2 0.3
3 1 0.1
4 0 –
5 4 0.2
6 1 0.2
7 0 –
8 1 0.3
9 0 –
10 0 –
Total 9 0.1
Hemolytic Uremic Syndrome
12
9 7
9
0
5
10
15
2012 2013 2014 2015
Year
Male 4 (44%)
Female 5 (56%) 0
5
10
Age of Cases in Years
2015 Provisional Data
5
District Count Rate
1 23 2.8
2 25 3.9
3 47 6.5
4 23 6.3
5 109 6.2
6 125 19.5
7 3 1.1
8 3 0.8
9 6 1.3
10 14 2.9
Total 278 4.2
Shigella
161 117
1362
278
0
500
1000
1500
2012 2013 2014 2015
Year
Male 127 (46%)
Female 150 (54%) 0
25
50
75
Age of Cases in Years
2015 Provisional Data
6
District Count Rate
1 373 45.6
2 163 25.1
3 284 39.2
4 149 40.6
5 867 49.6
6 493 76.8
7 273 97.0
8 234 63.0
9 410 90.0
10 309 63.4
Total 3,555 54.3
Hepatitis C, Acute & Chronic
4528 4623 5475
3558
0
2000
4000
6000
2012 2013 2014 2015
Year
Male 2052 (58%)
Female 1500 (42%) 0
250
500
750
1000
Age of Cases in Years
2015 Provisional Data
7
District Count Rate
1 8 1.0
2 8 1.2
3 10 1.4
4 9 2.5
5 33 1.9
6 19 3.0
7 2 0.7
8 8 2.2
9 13 2.9
10 8 1.6
Total 118 1.8
Hepatitis C, Acute
112
139 122 118
0
50
100
150
2012 2013 2014 2015
Year
Male 65 (55%)
Female 53 (45%) 0
10
20
30
40
50
Age of Cases in Years
2015 Provisional Data
8
District Count Rate
1 1 0.1
2 0 –
3 1 0.1
4 0 –
5 0 –
6 2 0.3
7 1 0.4
8 0 –
9 1 0.2
10 0 –
Total 6 0.09
Meningococcal disease
8
15
4
9
0
5
10
15
20
2012 2013 2014 2015
Year
Male 2 (33%)
Female 4 (67%) 0
1
2
3
Age of Cases in Years
2015 Provisional Data
9
District Count Rate
1 1 0.1
2 1 0.2
3 1 0.1
4 0 –
5 1 0.06
6 0 –
7 1 0.4
8 0 –
9 1 0.2
10 0 –
Total 6 0.09
Mumps
4 4
24
6
0
10
20
30
2012 2013 2014 2015
Year
Male 2 (33%)
Female 4 (67%) 0
1
2
3
4
Age of Cases in Years
2015 Provisional Data
10
Hot Topics – Mumps virus
• 24 cases at Butler University
• 17 cases at Indiana University-Bloomington
• 4 cases at IUPUI
• 5 cases at Purdue University
11
Hot Topics (2) – Zika virus
• United States
– 346 Travel-associated cases in U.S.
• 32 pregnant women
• 7 sexual transmission
• 1 Guillian-Barre syndrome
– No locally acquired vector-borne cases
• Indiana
– 6 Travel-associated cases
– No sexual transmission
– No Guillian-Barre syndrome
12
Zika Virus: Transmission Routes
• Recently detected in
the Americas
– A. albopictus and
A. aegypti mosquito
• 3 patterns of spread
– Direct bites by infected
mosquito
– Trans-placental
– Sexual
13
Zika Virus Infection
• Most people do not have symptoms
• Signs and symptoms are non-specific
– Rash
– Fever
– Joint pain
– Headache
– Reddish eyes
14
Zika Virus Prevention
• Pregnant women
– Follow CDC’s travel guidance
– Do not travel to areas with Zika virus
– Use a condom or refrain from sex
• Everyone
– Prevent mosquito bites
• Use insect repellant
• Cover your skin
15
Major Outbreak Responses
(2015)
16
Meningococcal Disease Mass
Prophylaxis (Allen Co. )
• 1 identified case in a school staff member (Dec. 2015)
• Case was a person employed at an elementary school who had
intermittent close contact with many students.
• The Local Health Department worked with the Hospital pharmacy
and school to provide prophylaxis
• Mass prophylaxis clinic was held at the school
• Approximately 500 students and staff received antibiotic post-
exposure prophylaxis
– Each of the 300+ students had to be weighed to determine appropriate dose of
suspension medication.
17
Shigella Outbreak 2014 (Central IN)
• Shigellosis transmission among daycare and school
attendees
• 854 S. sonnei cases from 9 counties were identified
• 749 of 854 cases (88%) were treated with antibiotics
regardless of severity.
• Indiana daycare/school exclusion policy encouraged
antibiotic treatment.
• CD Rule was revised to decrease antibiotic treatment
requirements and decrease antibiocitc resistance
emergence.
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The CD Rule
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CD Rule
• 410 IAC 1-2.3 repealed
• 410 IAC 1-2.5 enacted December 25, 2015
• 410 IAC 1-2.5-75: Reporting requirements for
physicians and hospital administrators
• 410 IAC 1-2.5-76: Laboratories; reporting requirements
• 410 IAC 1-2.5-77: Disease intervention measures;
responsibility to investigate and implement
20
Overview of the CD Rule
• Definitions
• Reporting requirements for physicians,
hospitals, and laboratories
• Disease intervention measures (general and
disease specific)
– Responsibilities
– Timeliness
• References
21
What’s New to the CD Rule?
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Reportable Diseases
• Newly reportable:
– Carbapenemase-producing Carbapenem-resistant
Enterobacteriaceae (CP-CRE)
– Chikungunya virus disease
– Cysticercosis (Taenia solium)
– Varicella-zoster virus
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Carbapenemase-Producing
Carbapenem-Resistant
Enterobacteriaceae
• Epidemiology – Can cause infections associated with high mortality rates (up to 50%)
due to resistant to carbapenem antibiotics and contain enzymes (carbapenemases) that
make carbapenems ineffective.
• Transmission – person to person via hands of HCPs or contact with infected stool,
wounds, or contaminated environmental surfaces (e.g. medical equipment)
• Incubation – not well defined
• Control Measures – The facility should initiate Contact Precautions; additional
precautions should be added if any other transmissible condition is present. AND…
– Can consider screening patients to determine if they are epidemiologically linked
– Can consider chlorhexidine gluconate bathing
• Laboratory Testing – Bacterial culture with antibiotic resistance susceptibility
testing.
24
Chikungunya virus disease
• Epidemiology
– Travel to Caribbean, Central/South America, other tropical and
subtropical areas
• Transmission
– Aedes aegypti and Aedes albopictus mosquitoes
• Incubation: 3–7 days
• Control measures
– Traveler education
– Mosquito bite prevention
• Laboratory testing: PCR, IgM/IgG serology
25
Taenia solium and
cysticercosis
• Epidemiology
– Underdeveloped areas with poor sanitation and pork consumption
– US: Latin American immigrants
• Transmission
– Ingestion of undercooked pork from a pig that has ingested human feces
(taeniasis)
– Ingestion of human feces (cysticercosis)
• Control measures:
– Cook meat to temperature
– Basic sanitation
• Laboratory testing: fecal microscopy, tissue biopsy
26
Varicella Zoster Virus (VZV) (newly LAB reportable)
• Epidemiology
– Varicella occurs worldwide. Humans are the only source of infection.
• Transmission
– Person-to-person transmission occurs via airborne route from infected
respiratory tract secretions or by direct contact with or inhalation of
aerosols from vesicular fluid of skin lesions.
• Incubation
– usually 14 to 16 days
• Control Measures
– school or child care setting exclusion until the rash has crusted.
• Laboratory Testing
– PCR or IgG Serology
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Latent Tuberculosis Infection (LTBI)
(Cases and Suspects still reportable) • Epidemiology
– Prevalence increases with age. Estimated that 1/3 of the human population is
infected (worldwide)
• Transmission
– TB is spread only by those with active TB disease, who expel tubercle bacilli via
aerosolized, droplet or airborne route through coughing, singing, or sneezing.
– People with Latent TB infections (LTBI) cannot infect others
• Incubation
– Latent TB: 2-10 weeks from infection to primary lesion or positive TST/IGRA
• Control Measures
– Prompt diagnoses and treatment of active TB disease
– Treatment of LTBI before progression to active disease
– Screening of high-risk population, including HIV positive and homeless individuals
• Laboratory Testing
– Test for infection only, further evaluation need for distinction between TB/LTBI
– Tuberculin Skin Test (TST) using a purified protein derivate (PPD)
– Interferon Gamma Release Assay (IGRA) of blood
28
Reportable Diseases
• Scientific name change:
– Anaplasma phagocytophilum (formerly Ehrlichia
phagocytophilum)
• To be removed from the reportable list:
– Streptococcus Group B Invasive Disease
29
Isolate Reportable Changes
• Newly required:
– Carbapenemase-producing Carbapenem-resistant
Enterobacteriaceae (CP-CRE)
– Shigella species
– Vibrio cholerae
– Vibrio species (other than toxigenic Vibrio
cholerae)
• No longer required:
– Nocardia
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Isolate Reportable Changes
• Require specimen submission for organisms
detected by a culture-independent diagnostic
test (CIDT):
– Shiga toxin-producing E. coli (STEC)
– Salmonella species
– Shigella species
– Vibrio cholera
– Vibrio species (other than toxigenic Vibrio
cholerae)
31
Timeliness Changes
• Laboratory: reporting timeliness now match
those for disease reporting
• Now reportable within 24 hours:
– Invasive Haemophilus influenzae (previously
immediately reportable)
– Mumps (previously reportable within 72 hours)
– Pertussis (previously immediately reportable)
32
Disease Specific Control
Measures
33
Animal Bites
• ANY rabies vector species (including bats,
skunks, raccoons, foxes, and other wild
carnivores) must be euthanized and tested
for rabies after a human bite, even if the
animal is being kept as a pet and/or permitted
by the Indiana DNR.
• Authorization to make exceptions to this
section is granted to the local health officer
and/or State Veterinarian.
34
Animal Bites (cont.)
• Language permitting euthanasia and rabies
testing of “stray or unwanted” biting animals
has been removed. These animals must now
be quarantined for 10 days after a bite.
• Unhealthy or terminally injured animals may
still be euthanized and tested.
35
Arboviral Diseases
• Dengue, chikungunya, EEE, SLE, WEE, West
Nile virus, California serogroup viruses, and
Powassan virus
• All will remain reportable, but will now be
listed separately on the reportable disease
list, as well as under the general term
“arboviral disease”.
• Note: formerly “Encephalitis, arboviral”
36
Food Employee Exclusions
• Specific to Hepatitis A, Shiga toxin-producing
E. coli (STEC), Salmonellosis, Shigellosis,
and Typhoid Fever.
• Aligned with the Retail Food Establishment
Sanitation Requirements (410 IAC 7-24)
proposed revisions.
37
Food Employee Exclusions
• Some examples of the alignment between the
CD Rule and the Food Code…
– “Ready-to-eat” was defined and the its use was
expanded to be included in Hepatitis A
– In regards to Shigella, the rule now clarifies when
to restrict and re-instate food employees
38
Influenza-associated Death
• Definition has been expanded to include
“listed anywhere on the death certificate as
primary, secondary, or contributory cause of
death” as a means by which an influenza
diagnosis has been detected.
• Investigations by the local health officer shall
now include an epidemiologic investigation.
39
Influenza-associated Death
(cont.)
What the rule says:
• A report is not necessary if the diagnosis of influenza is
neither confirmed by laboratory testing nor listed on the
death certificate as primary, secondary, or contributory
cause of death on the death certificate.
What the rule means:
• Influenza-associated death is only reportable if
laboratory confirmed or listed on the death certificate
as a primary, secondary, or contributory cause of
death.
40
Measles School Exclusions
• Anyone who gets a first or second dose of MMR as
part of an outbreak control program can return
immediately to school as long as all persons without
documented proof of immunity have been excluded
and that vaccination occurred within 72 hours of
exposure.
• Previous rule did not address case contacts who
received vaccination as part of an outbreak response
41
Measles and Mumps Health
Care Facility Exclusions
• All exposed employees without proof of immunity
must be excluded from day 5-21 (for measles) and
day 9-25 (for mumps) after exposure, regardless of
vaccination or if IG was given after exposure.
• This was a clarification added to the rule, as the
previous version of the rule did not directly address
this
42
Shigella Exclusion
• Daycare & pre-school attendees will be able to return to
school after 48 hours if they…
– Are asymptomatic
– Received antibiotic treatment
– Submit 1 negative stool sample
• Healthcare workers, and daycare workers will be able
to return to work after 24 hours if they…
– Are asymptomatic;
– Submit 1 negative stool sample
43
Varicella
• Laboratory testing requirements for “break-through”
and hospitalized cases have been added.
– PCR
– Culture
– IgG paired serology
• Outbreak control measures added
– Defines an outbreak
– Provides guidance on exclusions and timelines
– Provides guidance on contact tracing
44
Link to the New CD Rule
410 Indiana Administrative Code (Full):
www.in.gov/legislative/iac/T04100/A00010.PDF
Or
Visit the ISDH website:
www.in.gov/isdh/25366.htm
45
Recorded Webinar
A pre-recorded Communicable Disease Reporting
Rule webinar is available at:
https://videocenter.isdh.in.gov/videos/video/2011/
46
2015
Reportable
Disease
List
47
Questions?
Josh Clayton, PhD, MPH
Deputy State Epidemiologist
Indiana State Department of Health
317-233-7009